Intranasal Medications

Dymista (fluticasone propionate 50 mcg/azelastine 137 mcg) - 1 spray each nostril BID for ages ≥12 years old
- Individual components FDA approved for children ≥2 (fluticasone propionate) and ≥5 (azelastine) years old

Intranasal Aerosols

QNASL (beclomethasone dipropionate) nasal aerosol - 1-2 sprays each nostril QD for ages ≥12 years old
Zetonna (ciclesonide) nasal aerosol - 1 spray each nostril QD for ages ≥12 years old
Usage notes for aerosols: tilt head back slightly, dispense the spray, hold breath for a few seconds, exhale through the mouth, avoid blowing nose for 15 min

Intranasal Capsaicin

SinusBuster, AllergyBuster (OTC)- Over 12 years old: 1–2 sprays each nostril up to TID (Max 12 sprays/day), <12 years: consult doctor
- Studies have shown symptomatic improvement in patients with vasomotor NAR treated with capsaicin

Intranasal Decongestants

Oxymetazoline 0.05% nasal spray (Afrin) - 2-3 sprays each nostril BID up to 5 days
- Alpha 1 and 2 agonist resulting in vasoconstriction, onset of action 5-10 min, duration of action 5-6 hours
- For AR, daily use (2 sprays each nostril QHS) with intranasal steroid more effective than nasal steroid alone without significant risk of developing rhinitis medicamentosa

Oral Medications

Antihistamine Properties

Note
- Fexofenadine does not require dose adjustment in liver disease
- Sedation caused by non-sedating antihistamines:
  - Cetirizine can be sedating in usual doses
  - Loratadine can be sedating in higher than usual doses
  - Fexofenadine remains nonsedating, even in higher doses
- Many fruit juices (e.g. grapefruit, orange and apple) are organic anion transporting peptide (OATP) 1A2 inhibitors which are involved in the absorption of fexofenadine. Inhibition of intestinal OATP1A2 reduces serum levels of fexofenadine by up to 70%, possibly reducing its effectiveness
  - Patients should not drink fruit juice 4 hours before to 1-2 hours after taking fexofenadine

Leukotriene Receptor Antagonists (LTRA)

Singulair (Montelukast)
- 6 months - 5 years - 4 mg oral granules packet QD
- 2-5 years - 4 mg chewable tablet QD
- 6-14 years - 5 mg chewable tablet QD
- ≥15 years - 10 mg tablet QD

Treatment Recommendations

Practice Parameter (2008)

Monotherapy
Oral antihistamines oral (H1 receptor antagonists)	Less effective for nasal congestion than for other nasal symptoms Less effective for AR than INSs, with similar effectiveness to INSs for associated ocular symptoms Generally ineffective for non-AR, other choices are typically better for mixed rhinitis.
Intranasal antihistamines	Effectiveness for AR is equal or superior to oral 2nd-generation antihistamines with a significant effect on nasal congestion Less effective than nasal steroids Rapid onset of action (several hours or less) Azelastine nasal spray is approved for vasomotor rhinitis, appropriate choice for mixed rhinitis Side effects with intranasal azelastine are bitter taste and somnolence.
Leukotriene receptor antagonists (LTRAs)	Efficacy similar to oral antihistamines Approved for both rhinitis and asthma, can be considered when both conditions are present
Intranasal corticosteroids (INSs)	Most effective monotherapy for all symptoms of AR including congestion More effective than oral antihistamine + LTRA Onset of action is usually within 12 hours (slower than oral/intranasal antihistamines) PRN use (eg, >50% days use) is effective for seasonal AR Similar effectiveness to oral antihistamines for allergic conjunctivitis Effective for some cases of non-AR (NARES, vasomotor rhinitis) Local side effects are minimal, but nasal bleeding can occur, as well as rare nasal septal perforation (growth suppression)
Oral corticosteroids	A short course (5-7 days) might be appropriate for very severe nasal symptoms.
Oral decongestants	Pseudoephedrine reduces nasal congestion but side effects include insomnia, irritability, palpitations, and hypertension.
Intranasal decongestants	Useful for the short-term and possibly for episodic therapy of nasal congestion but inappropriate for daily use because of risk for rhinitis medicamentosa
Intranasal anticholinergic (ipratropium)	Reduces rhinorrhea only, rapid onset of action Particularly effective for preventing rhinorrhea of gustatory rhinitis Side effects are minimal, but nasal dryness can occur

Combination
Oral antihistamine + oral LTRA-------	More effective than monotherapy with either, but combination less effective than INS Alternative if patients are unresponsive/not compliant with INSs
Oral antihistamine + INS	Additional benefit of adding antihistamine to INS not supported by many studies
Intranasal cholinergic + INS	More effective for rhinorrhea than either drug alone
Intranasal antihistamine + INS	Limited data support additive benefit for AR and mixed rhinitis Inadequate data about the optimal interval between administration of the 2 sprays
Oral LTRA + INS	Provides subjective additive relief in limited studies; data are inadequate